Evidence Based Medicine and Workers' Compensation

Sunday, September 12, 2004 | 0

by Jeffrey Lambert RN, MS/HSA, CLCP, CPDM
CARRP North Bay Regional Representative

California has mandated the use of Evidence Based Medicine (EBM) guidelines for workers compensation claims in an effort to improve the system and control rising costs. In April 2004, Governor Schwarzenegger signed into law a requirement to develop and use EBM guidelines for the treatment of workers compensation injured/ill employees. Until such EMB guidelines are developed, adopted, and implemented by the Administrative Director for Workers Compensation, the American College of Occupational and Environmental Medicine (ACOEM) guidelines are to be used.

General health (group health) has used EBM guidelines for several years. Hospitals have used them to develop critical pathways, and utilization review programs have used them to provide management of the treatment plan. Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients (Oxford Center for EBM). EBM guidelines are not instructions on how to treat. They can inform, but they cannot replace the physician's clinical expertise. He or she decides if the guidelines apply to his or her individual patient, and how the guidelines should be integrated or used in regard to any clinical decision concerning an individual patient.

EBM does provide a framework, or foundation for clinical decision-making based on research, medical developments, and consensus among clinicians. Physicians who practice evidence-based medicine should identify and apply the most efficacious interventions to maximize the quality and quantity of life for individual patients; this may raise rather than lower the cost of their care. However, EBM guidelines can help to control the over utilization of treatments, excessive office visits, and if used correctly, can reduce the cost of workers' compensation claims. Workers' compensation claims, unfortunately, have a reputation for being excessive in terms of treatment modalities, and repeat office visits; usually coupled with poorly defined end-points of care for common injuries.

The outcome of some of these variances from common clinical practices in the workers' compensation arena have resulted in confusion, high costs, unsatisfactory outcomes of care, and in some cases increased disability. Healthcare costs are affecting our economy whether its workers compensation or general healthcare system costs. EBM protocols such as the ACOEM guidelines are a step in the right direction. Extensive peer review was done to evaluate the validity of these guidelines. According to the American College of Occupational Medicine, there was little divergence of opinion among the reviewers, who functioned as a consensus group. Pilot testing was done to gauge the reliability and utility of the guidelines in clinical practice.

In brief, the ACOEM guidelines offer protocols, which are limited to the care of acute and sub-acute conditions of workers from teens to 65 years of age. One should keep in mind that occupational medicine is a preventive specialty that emphasizes cost-effective strategies to prevent injury or illness in the work place. The ACOEM guidelines are there to offer information to the clinician; however, the clinician should continue to use their expertise when determining how these guidelines apply to the individual patient's care.

Reprinted by permission from the CARRP newsletter; California Association of Rehabilitation and Reemployment Professionals, www.carrp.org; Keeping California Working since 1975. br>
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